Form Approved
OMB No. 0920-0798
Exp. Date: 01/31/2011
Attachment 9
Consent to Participate in Consumer Focus Group
You are being asked to participate in a research study. RTI International is conducting a series of focus groups sponsored by the Centers for Disease Control and Prevention (CDC). The purpose of the focus groups is to learn about women’s health and healthy behaviors. You are eligible to take part in the discussions because you are a women aged 18-44. About 300 people total will take part in the discussions.
If you agree to participate, you will take part in a focus group in person for about 60-90 minutes.
An experienced interviewer from RTI will moderate the discussion. Another member of our project team will take notes during the interview. The discussion will also be audio recorded. The recordings will help us get everything you have to say. It is possible that someone from the CDC would be observing the groups so they can better understand your views and opinions. If they are observing, we will let you know. They will not actively participate during the discussion, but they may ask the moderator to follow up on a specific question at the end of the discussion.
We do not expect any risks to you from participating in the interview. It is possible that some of the things we discuss could make you uncomfortable; however, if you find that any of the questions make you uncomfortable, you do not have to answer them.
There are no direct benefits to you from answering the questions except the satisfaction of helping CDC better understand issues relating to women’s health and healthy behaviors so that they may develop better health information for women.
You will receive $75.00 for your time and effort to participate in the focus group.
Your answers will be used to write a summary report, but we will not use any real names in the report. Your name will not be given to anyone. The notes and the recordings will be kept in a locked file cabinet in the RTI office and will be destroyed after the project is completed.
RTI and CDC will not contact you in the future regarding this study.
Your decision to take part in this interview is completely voluntary. You can refuse any activity and you can stop participating at any time. You can refuse to answer any question. If you decide to participate and later change your mind, you will not be contacted again or asked for further information.
If you have any questions about the telephone discussions, you may call Dr. Linda Squiers at RTI at 301-576-8088. If you have any questions about your rights as a focus group participant, you may call RTI’s Office of Research Protection toll-free at 1-866-214-2043.
Please Read and Check Below if You Agree
I freely choose to take part in this research study. Date __________________________
Signature ___________________________ Printed Name _________________________
Public reporting burden of this collection of information is estimated to average 5 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0798)
| File Type | application/msword |
| File Title | Consent to Participate in Telephone Interview |
| Author | Karen Isenberg |
| Last Modified By | mlynch |
| File Modified | 2010-03-04 |
| File Created | 2010-01-19 |